{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T18:43:46Z","timestamp":1785782626720,"version":"3.56.0"},"reference-count":101,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2023,3,17]],"date-time":"2023-03-17T00:00:00Z","timestamp":1679011200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001691","name":"Japan Society for the Promotion of Science (JSPS)","doi-asserted-by":"publisher","award":["19K17729"],"award-info":[{"award-number":["19K17729"]}],"id":[{"id":"10.13039\/501100001691","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Therapeutic options with immunosuppressive agents for glomerular diseases have widened with refinements to the Kidney Disease Improving Global Outcomes (KDIGO) guidelines from 2012 to 2021. However, international guidelines do not necessarily match the reality in each country. Expensive therapies such as rituximab and calcineurin inhibitors are sometimes inaccessible to patients with refractory nephrotic syndrome due to cost or regulations. Under the Japanese medical insurance system, rituximab is accessible but still limited to steroid-dependent patients who developed idiopathic nephrotic syndrome in childhood. Based on international KDIGO guidelines and other national guidelines, possible applications of immunosuppressive agents for nephrotic syndrome are comprehensively examined in this review. While rituximab has become the mainstay of immunosuppressive therapy for nephrotic syndrome, clinical trials have indicated that options such as cyclophosphamide, calcineurin inhibitors, and mycophenolate mofetil would be preferable. Given the rising number of patients with nephrotic syndrome worldwide, KDIGO guidelines mention the need for further consideration of cost-effectiveness. If the new option of rituximab is to be the first choice in combination with steroids for nephrotic syndrome, its cost-effectiveness should also be verified. Among the few studies examining the cost-effectiveness of treatments for nephrotic syndrome, administration of rituximab to young adults has been shown to be cost-beneficial, at least in Japan. However, further large-scale studies involving multiple facilities are needed to verify such findings. Network meta-analyses have concluded that the efficacy of rituximab remains controversial and confirmation through high-quality studies of large cohorts is needed. To this end, the mechanisms of action underlying immunosuppressive agents, both old and new, need to be understood and experience must be accumulated to evaluate possible effects and side effects.<\/jats:p>","DOI":"10.3390\/medicina59030601","type":"journal-article","created":{"date-parts":[[2023,3,20]],"date-time":"2023-03-20T04:33:31Z","timestamp":1679286811000},"page":"601","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["Immunosuppressive Agent Options for Primary Nephrotic Syndrome: A Review of Network Meta-Analyses and Cost-Effectiveness Analysis"],"prefix":"10.3390","volume":"59","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5050-5291","authenticated-orcid":false,"given":"Kei","family":"Nagai","sequence":"first","affiliation":[{"name":"University of Tsukuba Hospital Hitachi Social Cooperation Education Research Center, Hitachi 317-0077, Ibaraki, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,3,17]]},"reference":[{"key":"ref_1","unstructured":"(2012). KDIGO Clinical Practice Guidelines for Glomerulonephropahy. Kidney Int. Suppl., 2, 139\u2013274."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1016\/S0140-6736(18)30536-1","article-title":"Idiopathic nephrotic syndrome in children","volume":"392","author":"Noone","year":"2018","journal-title":"Lancet"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2036","DOI":"10.1016\/S0140-6736(16)00272-5","article-title":"Primary glomerulonephritides","volume":"387","author":"Floege","year":"2016","journal-title":"Lancet"},{"key":"ref_4","first-page":"1011","article-title":"Patients with Idiopathic Membranous Nephropathy: A Real-World Clinical and Economic Analysis of U.S. Claims Data","volume":"25","author":"Nazareth","year":"2019","journal-title":"J. Manag. Care Spec. Pharm."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"393","DOI":"10.5414\/CNP58393","article-title":"Th1\/Th2 balance in childhood idiopathic nephrotic syndrome","volume":"58","author":"Kaneko","year":"2002","journal-title":"Clin. Nephrol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"779","DOI":"10.1007\/PL00013437","article-title":"Th1\/Th2 balance and CD45-positive T cell subsets in primary nephrotic syndrome","volume":"14","author":"Stachowski","year":"2000","journal-title":"Pediatr. Nephrol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1683","DOI":"10.1007\/s00467-009-1194-x","article-title":"The prevalence of Th17 cells and FOXP3 regulate T cells (Treg) in children with primary nephrotic syndrome","volume":"24","author":"Shao","year":"2009","journal-title":"Pediatr. Nephrol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"314","DOI":"10.1016\/j.clim.2011.02.018","article-title":"Th17\/Treg imbalance in adult patients with minimal change nephrotic syndrome","volume":"139","author":"Liu","year":"2011","journal-title":"Clin. Immunol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1033","DOI":"10.1007\/s00467-008-1092-7","article-title":"Increased nitric oxide production by T- and B-cells in idiopathic nephrotic syndrome","volume":"24","author":"Iharada","year":"2009","journal-title":"Pediatr. Nephrol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"823204","DOI":"10.3389\/fimmu.2022.823204","article-title":"B-Cell Dysregulation in Idiopathic Nephrotic Syndrome: What We Know and What We Need to Discover","volume":"13","author":"Colucci","year":"2022","journal-title":"Front. Immunol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"807","DOI":"10.4049\/jimmunol.141.3.807","article-title":"Massive proteinuria induced in rats by a single intravenous injection of a monoclonal antibody","volume":"141","author":"Orikasa","year":"1988","journal-title":"J. Immunol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1559","DOI":"10.1172\/JCI7728","article-title":"Nephritogenic mAb 5-1-6 is directed at the extracellular domain of rat nephrin","volume":"104","author":"Topham","year":"1999","journal-title":"J. Clin. Investig."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"238","DOI":"10.1681\/ASN.2021060794","article-title":"Discovery of Autoantibodies Targeting Nephrin in Minimal Change Disease Supports a Novel Autoimmune Etiology","volume":"33","author":"Watts","year":"2022","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1056\/NEJMoa0810457","article-title":"M-type phospholipase A2 receptor as target antigen in idiopathic membranous nephropathy","volume":"361","author":"Beck","year":"2009","journal-title":"N. Engl. J. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1038\/s41572-021-00303-z","article-title":"Membranous nephropathy","volume":"7","author":"Ronco","year":"2021","journal-title":"Nat. Rev. Dis. Prim."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2277","DOI":"10.1056\/NEJMoa1409354","article-title":"Thrombospondin type-1 domain-containing 7A in idiopathic membranous nephropathy","volume":"371","author":"Tomas","year":"2014","journal-title":"N. Engl. J. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"789713","DOI":"10.3389\/fimmu.2022.789713","article-title":"Therapies for Membranous Nephropathy: A Tale From the Old and New Millennia","volume":"13","author":"Scolari","year":"2022","journal-title":"Front. Immunol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"845767","DOI":"10.3389\/fimmu.2022.845767","article-title":"Novel Biomarkers in Membranous Nephropathy","volume":"13","author":"Liu","year":"2022","journal-title":"Front. Immunol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1038\/nrneph.2017.92","article-title":"Treatment of membranous nephropathy: Time for a paradigm shift","volume":"13","author":"Ruggenenti","year":"2017","journal-title":"Nat. Rev. Nephrol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"gfab356","DOI":"10.1093\/ndt\/gfab356","article-title":"The role of PLA2R antibody monitoring: What we know and what we don\u2019t know","volume":"2021","author":"Ronco","year":"2021","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Smarz-Widelska, I., Chojeta, D., and Koziol, M.M. (2022). The Role of Anti-PLA(2)R and Anti-THSD7A Antibodies in the Pathogenesis and Diagnostics of Primary Membranous Nephropathy: A Review of Current Knowledge for Clinical Practice. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph19095301"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"593288","DOI":"10.3389\/fimmu.2021.593288","article-title":"Autoantibodies in the Diagnosis, Monitoring, and Treatment of Membranous Nephropathy","volume":"12","author":"Tesar","year":"2021","journal-title":"Front. Immunol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1007\/s10157-014-1030-x","article-title":"Clinical practice guideline for pediatric idiopathic nephrotic syndrome 2013: Medical therapy","volume":"19","author":"Ishikura","year":"2015","journal-title":"Clin. Exp. Nephrol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1277","DOI":"10.1007\/s10157-021-02098-5","article-title":"A digest of the Evidence-Based Clinical Practice Guideline for Nephrotic Syndrome 2020","volume":"25","author":"Wada","year":"2021","journal-title":"Clin. Exp. Nephrol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2971","DOI":"10.1007\/s00467-021-05135-3","article-title":"Pediatric idiopathic steroid-sensitive nephrotic syndrome: Diagnosis and therapy -short version of the updated German best practice guideline (S2e)-AWMF register no. 166-001, 6\/2020","volume":"36","author":"Ehren","year":"2021","journal-title":"Pediatr. Nephrol."},{"key":"ref_26","unstructured":"Kidney Disease: Improving Global Outcomes Glomerular Diseases Work Group (2021). KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int., 100, S1\u2013S276."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"461","DOI":"10.1007\/s13312-021-2217-3","article-title":"Steroid Sensitive Nephrotic Syndrome: Revised Guidelines","volume":"58","author":"Sinha","year":"2021","journal-title":"Indian Pediatr."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"877","DOI":"10.1007\/s00467-022-05739-3","article-title":"IPNA clinical practice recommendations for the diagnosis and management of children with steroid-sensitive nephrotic syndrome","volume":"38","author":"Trautmann","year":"2023","journal-title":"Pediatr. Nephrol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"805697","DOI":"10.3389\/fimmu.2022.805697","article-title":"New and Old Anti-CD20 Monoclonal Antibodies for Nephrotic Syndrome. Where We Are?","volume":"13","author":"Basu","year":"2022","journal-title":"Front. Immunol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"303","DOI":"10.3389\/fmed.2020.00303","article-title":"Belimumab and Rituximab in Systemic Lupus Erythematosus: A Tale of Two B Cell-Targeting Agents","volume":"7","author":"Wise","year":"2020","journal-title":"Front. Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1007\/s00467-021-05175-9","article-title":"Belimumab for the treatment of children with frequently relapsing nephrotic syndrome: The BELNEPH study","volume":"37","author":"Vivarelli","year":"2022","journal-title":"Pediatr. Nephrol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1007\/s40620-013-0028-x","article-title":"Bortezomib therapy for nephrotic syndrome due to idiopathic membranous nephropathy","volume":"27","author":"Hartono","year":"2014","journal-title":"J. Nephrol."},{"key":"ref_33","first-page":"CD001533","article-title":"Corticosteroid therapy for nephrotic syndrome in children","volume":"2020","author":"Hahn","year":"2020","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1016\/j.jpeds.2005.03.050","article-title":"Children with steroid-sensitive nephrotic syndrome come of age: Long-term outcome","volume":"147","author":"Ruth","year":"2005","journal-title":"J. Pediatr."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"783","DOI":"10.1007\/s00467-003-1176-3","article-title":"Long-term linear growth of children with severe steroid-responsive nephrotic syndrome","volume":"18","author":"Emma","year":"2003","journal-title":"Pediatr. Nephrol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"2537","DOI":"10.1093\/ndt\/gfq097","article-title":"Behavioural abnormalities in children with nephrotic syndrome","volume":"25","author":"Mishra","year":"2010","journal-title":"Nephrol. Dial. Transpl."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1529","DOI":"10.1007\/s00467-020-04519-1","article-title":"IPNA clinical practice recommendations for the diagnosis and management of children with steroid-resistant nephrotic syndrome","volume":"35","author":"Trautmann","year":"2020","journal-title":"Pediatr. Nephrol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"444","DOI":"10.1681\/ASN.V93444","article-title":"A randomized study comparing methylprednisolone plus chlorambucil versus methylprednisolone plus cyclophosphamide in idiopathic membranous nephropathy","volume":"9","author":"Ponticelli","year":"1998","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"833611","DOI":"10.3389\/fped.2022.833611","article-title":"Structural Inequities and Barriers to Accessing Kidney Healthcare Services in the United States: A Focus on Uninsured and Undocumented Children and Young Adults","volume":"10","author":"Iorember","year":"2022","journal-title":"Front. Pediatr."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1007\/s004670050307","article-title":"Levamisole therapy in corticosteroid-dependent nephrotic syndrome","volume":"11","author":"Bagga","year":"1997","journal-title":"Pediatr. Nephrol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1007\/s13312-014-0419-7","article-title":"Efficacy of levamisole in children with frequently relapsing and steroid-dependent nephrotic syndrome","volume":"51","author":"Ekambaram","year":"2014","journal-title":"Indian Pediatr."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"883","DOI":"10.1042\/CS20140749","article-title":"Levamisole in steroid-sensitive nephrotic syndrome: Usefulness in adult patients and laboratory insights into mechanisms of action via direct action on the kidney podocyte","volume":"128","author":"Jiang","year":"2015","journal-title":"Clin. Sci."},{"key":"ref_43","first-page":"CD001537","article-title":"Interventions for minimal change disease in adults with nephrotic syndrome","volume":"3","author":"Azukaitis","year":"2022","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"102944","DOI":"10.1016\/j.jaut.2022.102944","article-title":"The landscape of T and B lymphocytes interaction and synergistic effects of Th1 and Th2 type response in the involved tissue of IgG4-RD revealed by single cell transcriptome analysis","volume":"133","author":"Cai","year":"2022","journal-title":"J. Autoimmun."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"741","DOI":"10.1146\/annurev.immunol.26.021607.090344","article-title":"T follicular helper (TFH) cells in normal and dysregulated immune responses","volume":"26","author":"King","year":"2008","journal-title":"Annu. Rev. Immunol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"236","DOI":"10.1038\/nri2729","article-title":"Effector and regulatory B cells: Modulators of CD4+ T cell immunity","volume":"10","author":"Lund","year":"2010","journal-title":"Nat. Rev. Immunol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1016\/j.jaut.2017.10.006","article-title":"NEPHRUTIX: A randomized, double-blind, placebo vs Rituximab-controlled trial assessing T-cell subset changes in Minimal Change Nephrotic Syndrome","volume":"88","author":"Boumediene","year":"2018","journal-title":"J. Autoimmun."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1111\/j.1365-2249.2009.04051.x","article-title":"Calcineurin inhibitors affect B cell antibody responses indirectly by interfering with T cell help","volume":"159","author":"Heidt","year":"2010","journal-title":"Clin. Exp. Immunol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1111\/cei.12604","article-title":"Calcineurin inhibitors dampen humoral immunity by acting directly on naive B cells","volume":"180","author":"Bogaert","year":"2015","journal-title":"Clin. Exp. Immunol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1191\/0961203305lu2060oa","article-title":"Cyclophosphamide in lupus nephritis","volume":"14","author":"Houssiau","year":"2005","journal-title":"Lupus"},{"key":"ref_51","first-page":"84","article-title":"Intravenous methylprednisolone and oral alkylating agent therapy of prednisone-resistant pediatric focal segmental glomerulosclerosis: A long-term follow-up","volume":"43","author":"Tune","year":"1995","journal-title":"Clin. Nephrol."},{"key":"ref_52","first-page":"53","article-title":"The impact of prolonged immunosuppression on the outcome of idiopathic focal-segmental glomerulosclerosis with nephrotic syndrome in adults. A collaborative retrospective study","volume":"36","author":"Banfi","year":"1991","journal-title":"Clin. Nephrol."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"1600","DOI":"10.1038\/ki.1995.453","article-title":"A 10-year follow-up of a randomized study with methylprednisolone and chlorambucil in membranous nephropathy","volume":"48","author":"Ponticelli","year":"1995","journal-title":"Kidney Int."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1097\/MOH.0000000000000393","article-title":"Cocaine\/levamisole-associated autoimmune syndrome: A disease of neutrophil-mediated autoimmunity","volume":"25","author":"Cascio","year":"2018","journal-title":"Curr. Opin. Hematol."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1016\/j.kint.2018.08.039","article-title":"Efficacy and safety of mycophenolate mofetil versus levamisole in frequently relapsing nephrotic syndrome: An open-label randomized controlled trial","volume":"95","author":"Sinha","year":"2019","journal-title":"Kidney Int."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"948","DOI":"10.1046\/j.1365-2133.1999.02833.x","article-title":"Purpura of the ears: A distinctive vasculopathy with circulating autoantibodies complicating long-term treatment with levamisole in children","volume":"140","author":"Rongioletti","year":"1999","journal-title":"Br. J. Derm."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"921","DOI":"10.1016\/j.semarthrit.2018.07.010","article-title":"Levamisole-induced vasculopathy: A systematic review","volume":"48","author":"Dartevel","year":"2019","journal-title":"Semin. Arthritis Rheum."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"2188","DOI":"10.1182\/blood.V90.6.2188","article-title":"IDEC-C2B8 (Rituximab) anti-CD20 monoclonal antibody therapy in patients with relapsed low-grade non-Hodgkin\u2019s lymphoma","volume":"90","author":"Maloney","year":"1997","journal-title":"Blood"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"1273","DOI":"10.1016\/S0140-6736(14)60541-9","article-title":"Rituximab for childhood-onset, complicated, frequently relapsing nephrotic syndrome or steroid-dependent nephrotic syndrome: A multicentre, double-blind, randomised, placebo-controlled trial","volume":"384","author":"Iijima","year":"2014","journal-title":"Lancet"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1111\/j.1749-6632.1993.tb17137.x","article-title":"The mechanism of action of FK-506 and cyclosporin A","volume":"696","author":"Wiederrecht","year":"1993","journal-title":"Ann. N. Y. Acad. Sci."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"32087","DOI":"10.1038\/srep32087","article-title":"Calcineurin inhibitors cyclosporin A and tacrolimus protect against podocyte injury induced by puromycin aminonucleoside in rodent models","volume":"6","author":"Shen","year":"2016","journal-title":"Sci. Rep."},{"key":"ref_62","first-page":"CD003594","article-title":"Interventions for idiopathic steroid-resistant nephrotic syndrome in children","volume":"2019","author":"Liu","year":"2019","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_63","first-page":"1659","article-title":"Mycophenolic acid morpholinoethylester (RS-61443) is a new immunosuppressant that prevents and halts heart allograft rejection by selective inhibition of T- and B-cell purine synthesis","volume":"22","author":"Morris","year":"1990","journal-title":"Transplant. Proc."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"2253","DOI":"10.1007\/s00467-018-3970-y","article-title":"Mycophenolate mofetil for sustained remission in nephrotic syndrome","volume":"33","author":"Querfeld","year":"2018","journal-title":"Pediatr. Nephrol."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"3547","DOI":"10.1016\/0006-2952(83)90301-5","article-title":"Genetic and biochemical studies on the activation and cytotoxic mechanism of bredinin, a potent inhibitor of purine biosynthesis in mammalian cells","volume":"32","author":"Koyama","year":"1983","journal-title":"Biochem. Pharm."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1002\/cbf.290070308","article-title":"Dual inhibitory effect of bredinin","volume":"7","author":"Kusumi","year":"1989","journal-title":"Cell Biochem. Funct."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1159\/000486943","article-title":"Direct Effects of Immunomodulatory Agents on Podocytes in Immune-Mediated Glomerular Diseases","volume":"195","author":"Manabe","year":"2018","journal-title":"Contrib. Nephrol."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"899","DOI":"10.1007\/s10157-013-0780-1","article-title":"Randomized comparative trial of mizoribine versus mycophenolate mofetil in combination with tacrolimus for living donor renal transplantation","volume":"17","author":"Takahara","year":"2013","journal-title":"Clin. Exp. Nephrol."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"317","DOI":"10.1046\/j.1523-1755.2000.00168.x","article-title":"A multicenter trial of mizoribine compared with placebo in children with frequently relapsing nephrotic syndrome","volume":"58","author":"Yoshioka","year":"2000","journal-title":"Kidney Int."},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"157","DOI":"10.3109\/03602538508991433","article-title":"The pharmacology and metabolism of the thiopurine drugs 6-mercaptopurine and azathioprine","volume":"16","author":"Johnson","year":"1985","journal-title":"Drug. Metab. Rev."},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"1005","DOI":"10.1124\/jpet.109.154948","article-title":"Oral administration of 1,4-aryl-2-mercaptoimidazole inhibits T-cell proliferation and reduces clinical severity in the murine experimental autoimmune encephalomyelitis model","volume":"331","author":"Jung","year":"2009","journal-title":"J. Pharm. Exp."},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"1133","DOI":"10.1172\/JCI16432","article-title":"CD28-dependent Rac1 activation is the molecular target of azathioprine in primary human CD4+ T lymphocytes","volume":"111","author":"Tiede","year":"2003","journal-title":"J. Clin. Investig."},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"73050","DOI":"10.18632\/oncotarget.20377","article-title":"Efficacy and safety of immunosuppressive medications for steroid-resistant nephrotic syndrome in children: A systematic review and network meta-analysis","volume":"8","author":"Li","year":"2017","journal-title":"Oncotarget"},{"key":"ref_74","first-page":"943","article-title":"Network meta-analysis: A technique to gather evidence from direct and indirect comparisons","volume":"15","author":"Tonin","year":"2017","journal-title":"Pharm. Pract."},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1136\/jim-2016-000163","article-title":"Comparison of second-line immunosuppressants for childhood refractory nephrotic syndrome: A systematic review and network meta-analysis","volume":"65","author":"Fu","year":"2017","journal-title":"J. Investig. Med."},{"key":"ref_76","doi-asserted-by":"crossref","first-page":"e15927","DOI":"10.1097\/MD.0000000000015927","article-title":"Efficacy and acceptability of immunosuppressive agents for pediatric frequently-relapsing and steroid-dependent nephrotic syndrome: A network meta-analysis of randomized controlled trials","volume":"98","author":"Tan","year":"2019","journal-title":"Medicine"},{"key":"ref_77","doi-asserted-by":"crossref","unstructured":"Ren, S., Wang, Y., Xian, L., Toyama, T., Jardine, M., Li, G., Perkovic, V., and Hong, D. (2017). Comparative effectiveness and tolerance of immunosuppressive treatments for idiopathic membranous nephropathy: A network meta-analysis. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0184398"},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"562","DOI":"10.1007\/s10157-017-1484-8","article-title":"Immunosuppressive therapy for steroid-resistant nephrotic syndrome: A Bayesian network meta-analysis of randomized controlled studies","volume":"22","author":"Jiang","year":"2018","journal-title":"Clin. Exp. Nephrol."},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"e030919","DOI":"10.1136\/bmjopen-2019-030919","article-title":"Comparative efficacy of 13 immunosuppressive agents for idiopathic membranous nephropathy in adults with nephrotic syndrome: A systematic review and network meta-analysis","volume":"9","author":"Zheng","year":"2019","journal-title":"BMJ Open"},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"107376","DOI":"10.1016\/j.intimp.2021.107376","article-title":"Efficacy and cost of different treatment in patients with idiopathic membranous nephropathy: A network meta-analysis and cost-effectiveness analysis","volume":"94","author":"Dai","year":"2021","journal-title":"Int. Immunopharmacol."},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"917532","DOI":"10.3389\/fphar.2022.917532","article-title":"Efficacy and safety of 12 immunosuppressive agents for idiopathic membranous nephropathy in adults: A pairwise and network meta-analysis","volume":"13","author":"Liu","year":"2022","journal-title":"Front. Pharm."},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"1159","DOI":"10.1007\/s40620-022-01268-2","article-title":"Immunosuppression therapy for idiopathic membranous nephropathy: Systematic review with network meta-analysis","volume":"35","author":"Bose","year":"2022","journal-title":"J. Nephrol."},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"903","DOI":"10.1007\/s10157-012-0673-8","article-title":"Renal disease in the elderly and the very elderly Japanese: Analysis of the Japan Renal Biopsy Registry (J-RBR)","volume":"16","author":"Yokoyama","year":"2012","journal-title":"Clin. Exp. Nephrol."},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"168","DOI":"10.1111\/nep.12739","article-title":"Increasing prevalence of membranous nephropathy in patients with primary glomerular diseases: A cross-sectional study in China","volume":"22","author":"Tang","year":"2017","journal-title":"Nephrology"},{"key":"ref_85","doi-asserted-by":"crossref","unstructured":"Li, Y., Yu, X., Zhang, W., Lv, J., Lan, P., Wang, Z., Sun, J., Xie, L., Lu, W., and Feng, X. (2022). Epidemiological characteristics and pathological changes of primary glomerular diseases. PLoS ONE, 17.","DOI":"10.1371\/journal.pone.0272237"},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1056\/NEJMoa1814427","article-title":"Rituximab or Cyclosporine in the Treatment of Membranous Nephropathy","volume":"381","author":"Fervenza","year":"2019","journal-title":"N. Engl. J. Med."},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1681\/ASN.2016040449","article-title":"Rituximab for Severe Membranous Nephropathy: A 6-Month Trial with Extended Follow-Up","volume":"28","author":"Dahan","year":"2017","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"e19804","DOI":"10.1097\/MD.0000000000019804","article-title":"Efficacy and safety of rituximab in the treatment of membranous nephropathy: A systematic review and meta-analysis","volume":"99","author":"Lu","year":"2020","journal-title":"Medicine"},{"key":"ref_89","doi-asserted-by":"crossref","first-page":"l1800","DOI":"10.1136\/bmj.l1800","article-title":"Long term tapering versus standard prednisolone treatment for first episode of childhood nephrotic syndrome: Phase III randomised controlled trial and economic evaluation","volume":"365","author":"Webb","year":"2019","journal-title":"BMJ"},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"1073","DOI":"10.34067\/KID.0005072021","article-title":"The Health Economic Impact of Nephrotic Syndrome in the United States","volume":"3","author":"Simon","year":"2022","journal-title":"Kidney360"},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"60","DOI":"10.2215\/CJN.0000000000000017","article-title":"Global, Regional, and National Burden of CKD due to Glomerulonephritis from 1990 to 2019: A Systematic Analysis from the Global Burden of Disease Study 2019","volume":"18","author":"Hu","year":"2023","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"14","DOI":"10.2215\/CJN.0000000000000029","article-title":"Trends in the Global Burden of Glomerulonephritis","volume":"18","author":"Bose","year":"2023","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"e001445","DOI":"10.1136\/bmjgh-2019-001445","article-title":"Socioeconomic inequality in life expectancy in India","volume":"4","author":"Asaria","year":"2019","journal-title":"BMJ Glob. Health"},{"key":"ref_94","doi-asserted-by":"crossref","unstructured":"Banerjee, S., and Roy Chowdhury, I. (2020). Inequities in curative health-care utilization among the adult population (20\u201359 years) in India: A comparative analysis of NSS 71st (2014) and 75th (2017-18) rounds. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0241994"},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1007\/s10157-016-1266-8","article-title":"Long-term efficacy and safety of common steroid-sparing agents in idiopathic nephrotic children","volume":"21","author":"Basu","year":"2017","journal-title":"Clin. Exp. Nephrol."},{"key":"ref_96","doi-asserted-by":"crossref","first-page":"46036","DOI":"10.1038\/srep46036","article-title":"Cost-Effectiveness of Administering Rituximab for Steroid-Dependent Nephrotic Syndrome and Frequently Relapsing Nephrotic Syndrome: A Preliminary Study in Japan","volume":"7","author":"Takura","year":"2017","journal-title":"Sci. Rep."},{"key":"ref_97","doi-asserted-by":"crossref","first-page":"2145","DOI":"10.1093\/ndt\/gfy049","article-title":"Rituximab versus the modified Ponticelli regimen in the treatment of primary membranous nephropathy: A Health Economic Model","volume":"33","author":"Hamilton","year":"2018","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_98","doi-asserted-by":"crossref","first-page":"1241","DOI":"10.1111\/nep.13554","article-title":"Persistent CD-19 depletion by rituximab is cost-effective in maintaining remission in calcineurin-inhibitor dependent podocytopathy","volume":"24","author":"Ramachandran","year":"2019","journal-title":"Nephrology"},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"110","DOI":"10.1159\/000486941","article-title":"Socioeconomics of Administering Rituximab for Nephrotic Syndrome","volume":"195","author":"Takura","year":"2018","journal-title":"Contrib. Nephrol."},{"key":"ref_100","doi-asserted-by":"crossref","first-page":"1225","DOI":"10.1093\/ndt\/gfs515","article-title":"Effect of single-dose rituximab on steroid-dependent minimal-change nephrotic syndrome in adults","volume":"28","author":"Takei","year":"2013","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_101","doi-asserted-by":"crossref","first-page":"850","DOI":"10.1681\/ASN.2013030251","article-title":"Rituximab in steroid-dependent or frequently relapsing idiopathic nephrotic syndrome","volume":"25","author":"Ruggenenti","year":"2014","journal-title":"J. Am. Soc. 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